Rotator Cuff Tear Treatment and Surgery | Update on stem cell therapy
Ross Hauser, MD discusses the problems of Rotator Cuff Injury and treatment options.
- New research suggests Prolotherapy effective for rotator cuff injuries in patients who failed to respond to conservative treatment.
- Studies show that arthroscopic surgical repair for rotator cuff tears and injuries results in outcomes no better than treatment with exercise or physical therapy alone.
- Athletes and young professionals favor rotator cuff surgery under the belief that that is their best way back to being active sooner – however research says that being active sooner may cause surgical failure.
- Arthroscopic rotator cuff tear repairs have a high percentage of re-tear risk and frequently result in side effects such as continued pain, stiffness and decreased range of motion.
- Surgical intervention for rotator cuff pain based on MRI’s are often misleading, as studies show the presence of MRI confirmed rotator cuff tears in individuals with absolutely no symptoms.
- Doctors point to Stem Cell Therapy, Platelet Rich Plasma Therapy, and Prolotherapy as viable options.
Stem cell therapy research into rotator cuff repair confirms what doctors know. “Despite improved surgical techniques, the tendon-to-bone healing rate is unsatisfactory due to difficulties in restoring the delicate transitional tissue between bone and tendon. “1 This same research from doctors in Spain publishing in May 2015 also says Mesenchymal stem cell therapy is a potentially effective therapy to enhance rotator cuff healing.
These researchers base this opinion on the fact that stem cell therapy increases the amount of fibrocartilage formation. This is the tissue that helps comprise ligaments, tendons, and cartilage and are specifically marked for studies on tissue engineering.
Stem Cell Therapy treatment to the shoulder
Rotator Cuff Surgery, Safety and Side Effects
Rotator cuff injuries are common causes of shoulder pain. The most common cause of chronic shoulder complaints in the athlete is rotator cuff tendonitis or tendonosis, specifically weakness of the supraspinatous tendon. For example, in pitching, the arm is repeatedly abducted and externally rotated, putting a strain on the rotator cuff and resulting in frequent tears or injuries. Poor circulation in the rotator cuff tendon increases the likelihood that degeneration of the tendon will occur with repeated injury.
Non-operative management consists of the use of analgesics, anti-inflammatory medications, physical therapy and steroid injections. Surgical intervention includes debridement of the degenerate cuff and partial thickness cuff tears, as well as rotator cuff repairs.
While surgery may “fix” the problem, new research is showing a high rate of rotator cuff re-tears within six months of shoulder surgery. A study done in Australia followed 500 consecutive patients who had rotator cuff surgeries.2
The outcome was a 57% rate of re-tear in the rotator cuff. The greatest risk for re-tear was the size of the original tear, indicating the difficulty in surgically repairing a large rotator cuff tear.
Effectiveness and safety of surgery and growing concern over Rotator Cuff Surgery Failures
There is a growing concern over Rotator Cuff Surgery Failures.
This is why there is also a growing interest in biotherapies such as Stem Cell Therapy, Platelet Rich Plasma Therapy, and for non-surgical approaches including Prolotherapy an alternative to rotator cuff surgery. Surgery involves the permanent alteration of the body and when it comes to the rotator cuff, the major stabilizer of the shoulder, surgery can cause more harm than good. The rotator cuff is a group of four muscles whose main function is to stabilize and provide support for the shoulder. It’s estimated that 10-70% of rotator cuff repairs form a recurrent defect following surgery.
- In a study out of the Cleveland Clinic, researchers studied 14 patients who underwent arthroscopic rotator cuff repair. In each patient, markers were placed in the repaired tendons so that researchers could use a CT scan to assess any tendon retraction. Patients were assessed at 6, 12, 26 and 52 weeks after operation. Results showed that within the first year all 14 repairs retracted away from the initial fixation position. While not all repairs resulted in recurrent tendon defects, the early retractions correlated with tendon defects. Researchers noted that this “failure with continuity” is common after rotator cuff repair and suggest repairs be protected in the early post-operative period.3
- A Cochrane systematic review of various studies of interventions for shoulder disorders set out to determine the effectiveness and safety of surgery for rotator cuff injuries.4 The researchers examined 14 studies involving shoulder surgery for rotator cuff disease. The results were not in favor of surgery and found that it may not lead to any difference in pain compared to exercise or physical therapy programs. Safety concerns were raised as surgery side effects included pain, infection, trouble moving the shoulder, muscle wasting, and follow-up surgeries. In fact, the side effects from arthroscopic surgery were no different from those who had open surgery, a much more invasive surgery. Patients with failed rotator cuff syndrome, that is, those with continued rotator cuff pain, weakness, and limited active range of motion following arthroscopic rotator cuff repair, present a diagnostic and therapeutic challenge to their surgeons.5
- Shoulder stiffness is a frequent complication of rotator cuff surgery, which negatively affects surgical outcomes leading to a substantial comorbidity and the failure of surgical treatment.6
MRIs of the shoulder are often misleading and lead to unnecessary rotator cuff surgery
MRIs are frequently used as the basis for determining the need for surgery; however, as with other areas of the body, a shoulder MRI can be very misleading. Some studies have shown that MRIs done on completely asymptomatic individuals show a high prevalence of tears of the rotator cuff. In one study 89 percent of the MRIs on totally asymptomatic shoulders showed abnormalities in the rotator cuff.7
- In another study by Jerry Sher, M.D. and associates, 34 percent of the individuals showed a partial tear of the rotator cuff and 15 percent showed complete full-thickness tears. These again were in people with full range of motion of their shoulders with absolutely no symptoms. His conclusion was that surgical intervention based on MRI findings alone is not warranted.8
Studies have shown that physical examination is actually better for diagnosing shoulder injuries than MRI. Use caution if a surgeon wants to scope or scalpel you based solely on MRI findings. In 2011, the New York Times reported a story from a well-known sports orthopedist by the name of Dr. James Andrews in Florida. This orthopedist suspected that MRI results are often misleading.
Seeing that most injured athletes and active people receive MRIs when faced with a sports injury, Dr. Andrews set out to see what MRIs showed on people with no pain or symptoms at all. He performed an MRI on 31 perfectly healthy professional baseball players. The results? 90% showed abnormal shoulder cartilage and 87% showed abnormal rotator cuff cartilage despite a 0% incidence of pain!
The article goes on to cite a few other well known orthopedists who explain that MRIs are sensitive but not specific and that abnormalities are usually inconsequential. In fact there are almost never “normal” MRIs. Unfortunately the use of MRIs has become so common that people believe good and accurate care must involve ordering a fancy test. Many of these doctors cited agree that a proper diagnosis can be made by taking a thorough physical and historical evaluation.
Rotator Cuff Injury Treatment with Prolotherapy and Platelet Rich Plasma as Successful Alternatives to Surgical Rotator Cuff Repair
Prolotherapy and Platelet Rich Plasma Therapy (PRP) are excellent alternatives to shoulder surgery for a torn rotator cuff and shoulder pain. Here’s what the researchers say:
- “Repairs of degenerate and torn tissue are often prone to failure due to many intrinsic and extrinsic factors. It is assumed that some biological therapies might improve clinical, mechanical, and histologic outcomes. Injections of platelet-rich plasma (PRP) have led to reduced pain and improved recovery in other degenerate pathologies areas together with the restoration of function.”9
- “Platelet-rich plasma promoted cell proliferation and enhanced gene expression and the synthesis of tendon matrix in tenocytes from human rotator cuff tendons with degenerative tears…These findings suggest that PRP might be used as a useful biological tool for regenerative healing of rotator cuff tears.”10
In another study PRP was added during an arthroscopic rotator cuff repair. The results showed a decrease in the incidence of MRI-observed re-tears and supports the use of PRP to “augment and enhance the healing of arthroscopic rotator cuff tears.”11 Of course with what we have discussed so far of the negative results from arthroscopic repair compared to the success we have seen with Prolotherapy and PRP in treating rotator cuff injuries, it would be beneficial to go straight to the PRP and forego the surgery.
Prolotherapy is an excellent option for rotator cuff injuries because it involves the regeneration of soft tissue. Surgery does just the opposite. Surgery involves removing part of bone, removing swollen bursa, or removing tissue. Unfortunately when parts of these supporting structures are removed the shoulder is susceptible to further degeneration. In a published study conducted with our own patients – we showed the benefits of Prolotherapy as an alternative to joint surgery. Thirty-four chronic pain patients who were told by their medical doctor/surgeon that surgery was needed were treated with Hackett-Hemwall dextrose Prolotherapy in lieu of surgery. Twenty of these patients were faced with joint replacements and nine with arthroscopic procedures.12
- In this study, Prolotherapy caused significant improvement in pain and stiffness.
- Ninety-one percent of patients felt Prolotherapy gave them 50% or greater pain relief, and 71% felt the pain relief was greater than 75%.
- The patients’ quality of life was improved as depression, anxiety, and medication usage decreased while range of motion, sleep and exercise ability increased.
- Prolotherapy was able to eliminate the need for surgery realistically in 31 out of 34 patients.13
- In the most recent research Prolotherapy showed improvement in pain, disability, isometric strength, and Range of Motion in patients with refractory chronic rotator cuff disease. 14
Prolotherapy is a simple injection therapy with a short recovery time and allows use of the shoulder during recovery. Prolotherapy is a first-line alternative to a costly and invasive surgery, which addresses the root cause of the problem (often missed by surgery), and leads to a better recovery.
*Note- Knowing whether the rotator cuff tendon is completely torn is imperative in order to determine the best course of action. A complete rotator cuff tear needs immediate surgical repair. This is usually manifested by an inability to lift the arm overhead and is almost always the result of severe trauma. Those with complete rotator cuff tears will only be able to move their shoulders about 30 degrees on their own, and will have good range of motion away from the body only if someone else moves the arm. Any other type of rotator cuff injury can be treated successfully with Prolotherapy and surgery can be avoided. Avoiding surgery should be a goal for anyone with a rotator cuff injury. In the event of failed rotator cuff surgery, Prolotherapy can address and cure the residual pain and stiffness.
References for this article
1. Mora MV, Ibán MA, Heredia JD, Laakso RB, Cuéllar R, Arranz MG. Stem cell therapy in the management of shoulder rotator cuff disorders. World J Stem Cells. 2015 May 26;7(4):691-9. doi: 10.4252/wjsc.v7.i4.691.
2. Harrison, L. Study Shows 57% Failure in Large Rotator Cuff Repairs. Retrieved March 5, 2012
3. Coghlan JA, Buchbinder R, Green S, Johnston RV, Bell SN. Surgery for rotator cuff disease. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.:DOI:10.1002/14651858.CD005619.pub2.
4. Strauss EJ, McCormack RA, Onyekwelu I, Rokito AS. Management of failed arthroscopic rotator cuff repair.J Am Acad Orthop Surg. 2012 May;20(5):301-9.
5. McCarron JA, Derwin KA, et al. Failure With Continuity in Rotator Cuff Repair “Healing”. Am J Sports Med. 2012 Sep 27.
6. Papalia R, Franceschi F, Vasta S, Gallo A, Maffulli N, Denaro V. Shoulder stiffness and rotator cuff repair. Br Med Bull. 2012 Feb 14. [Epub ahead of print]
7. Farley TE, Neumann CH, Steinbach LS, Petersen SA.The coracoacromial arch: MR evaluation and correlation with rotator cuff pathology.Skeletal Radiol. 1994 Nov;23(8):641-5.
8. Sher JS, Iannotti JP, Williams GR, Herzog RJ, Kneeland JB, Lisser S, Patel N. The effect of shoulder magnetic resonance imaging on clinical decision making.J Shoulder Elbow Surg. 1998 May-Jun;7(3):205-9.
9. Mei-Dan O, Carmont MR. The role of platelet-rich plasma in rotator cuff repair.Sports Med Arthrosc. 2011 Sep;19(3):244-50.
10. Jo CH, Kim JE Yoon S, et al. Platelet-Rich Plasma Stimulates Cell Proliferation and Enhances Matrix Gene Expression and Synthesis in Tenocytes From Human Rotator Cuff Tendons With Degenerative Tears. Am J Sports Med May 2012 vol. 40 no. 5 1035-1045.
11. Barber FA, Hmack SA, Snyder SJ, Hapa O. Rotator cuff repair healing influenced by platelet-rich plasma construct augmentation. Arthroscopy: The Journal of Arthroscopy and Related Surgery.2011; 27(8):1029-1035.
12. Hauser RA, Hauser, MA. A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Shoulder Pain at an Outpatient Charity Clinic in Rural Illinois. Journal of Prolotherapy. 2009;4:205-216.
13. Hauser, RA, et al. Prolotherapy as an Alternative to Surgery: A Prospective Pilot Study of 34 Patients from a Private Medical Practice. Journal of Prolotherapy. 2010;(2)1:272-281.
14. Lee DH, Kwack KS, Rah UW, Yoon SH. Prolotherapy for refractory rotator cuff disease: retrospective case-control study of one year follow-up. Arch Phys Med Rehabil. 2015 Aug 5. pii: S0003-9993(15)00594-8. doi: 10.1016/j.apmr.2015.07.011. [Epub ahead of print]